<div>
	<div class="col-xs-3">
		<label>Скидка:</label>
	</div>
	<div class="col-xs-3">
		<input type="number" class="form-control" placeholder=".col-xs-2">
	</div>
	<div class="col-xs-3">
		<input type="number" class="form-control" placeholder=".col-xs-2">
	</div>
	<div class="col-xs-3">
		<input type="number" class="form-control" placeholder=".col-xs-2">
	</div>	
</div>
<br>
<br>
<div>
	<div class="col-xs-3">
		<label>Количество:</label>
	</div>
	<div class="col-xs-3">
		<input type="number" class="form-control" placeholder=".col-xs-2">
	</div>
</div>
<br>
<br>
<div>
	<div class="col-xs-2">
		<label>Без скидки:</label>
	</div>
	<div class="col-xs-4">
		<input type="text" class="form-control" placeholder=".col-xs-2">
	</div>
	<div class="col-xs-2">
		<label>Со скидкой:</label>
	</div>
	<div class="col-xs-4">
		<input type="text" class="form-control" placeholder=".col-xs-2">
	</div>
</div>
<br>
<br>
<br>
<div align="right">
	<button type="button" class="btn btn">Отмена</button>
	<button type="button" class="btn btn-primary" onclick="uiOperator.loadOrder();">Готово</button>
</div>